Trends in the use of the Italian Mental Health Act, 1979–1997

Zero Tolerance for Coercion? Historical, Cultural and Organisational Contexts for Effective Implementation of Coercion-Free Mental Health Services around the World

Coercion of service users/patients when receiving care and treatment has been a serious dilemma for mental health services since at least the 18th century, and the debate about how best to minimise or even eradicate compulsion remains intense. Coercion is now, once again and rightly, at the top of the international policy agenda and the COST Action 'FOSTREN' is one example of a renewed commitment by service user advocates, practitioners and researchers to move forward in seriously addressing this problem. The focus of service improvement efforts has moved from pure innovation to practical implementation of effective interventions based on an understanding of the historical, cultural and political realities in which mental health services operate. These realities and their impact on the potential for change vary between countries across Europe and beyond. This article provides a novel overview by focusing on the historical, cultural and political contexts which relate to successful implementation primarily in Europe, North America and Australasia so that policy and practice in these and other regions can be adopted with an awareness of these potentially relevant factors. It also outlines some key aspects of current knowledge about the leading coercion-reduction interventions which might be considered when redesigning mental health services.

Beyond Patient Characteristics: A Narrative Review of Contextual Factors Influencing Involuntary Admissions in Mental Health Care

Variations in the rates of involuntary admission (IA) reflect the influence of unexplained contextual variables that are typically too heterogeneous to be included in systematic reviews. This paper attempts to gather and analyze factors unrelated to the patients that have been linked to IA. The articles included in this review were selected by iteratively searching four electronic databases (PubMed, PsychINFO, EMBASE, and Web of Science). A total of 54 studies from 19 different countries and regions, including 14 European countries, the United States, Canada, China, Vietnam, and Taiwan, were selected. The factors were categorized as service-related factors, impactful events, seasonal and temporal factors, mental health legislation, staff factors, and public attitudes. The factors rarely act in isolation but rather interact and reinforce each other, causing a greater influence on IA. This paper explains how these factors present opportunities for robust and sustainable interventions to reduce IAs. The paper also identifies future directions for research, such as examining the effects of economic recessions. Enhancing global reporting standards is essential to validate future research and support further in-depth studies. The complexity of the factors influencing IA and the implicit role of society suggest that resolving it will require social change.

40th birthday of the Italian Mental Health Law 180 - perception and reputation abroad, and a personal suggestion

How things are perceived from a distance may help better understand their nature. Perceptions at home are likely to shape perceptions abroad. The mutual cross-references between local and distant perspectives on the Italian Mental Health Law 180 may help understand the process which preceded and resulted in the reform. This editorial argues that Law 180 came about at a unique - enabling - time in history. It argues that the run-up to and passing of Law 180 constituted a great accomplishment by professionals, the wider public and politicians/administrators. This editorial goes on to argue that the profession managed to cope with (many) adverse effects of the reform. The attention that Law 180 has received internationally should be devoted to other national (or regional) mental health reform processes as this may help us to understand how mental health care systems evolve and what defines 'windows of (operative) opportunity' or 'moments for (public) action'.

Compulsory Psychiatric Admissions in an Italian Urban Setting: Are They Actually Compliant to the Need for Treatment Criteria or Arranged for Dangerous Not Clinical Condition?

Background: Italy was one of the first European countries adopting the need for treatment criteria for compulsory admission (CA). The aim of the present study was to confirm whether CA in an urban setting in Italy was compliant with the requested clinical criteria. Methods: In this retrospective observational study, we retrieved all collected information regarding CA in Turin (Italy) from January 2006 to December 2013. All content and data reported in the CA forms, including diagnosis and clinical details, were gathered and analyzed. Comparisons between CA with and without a diagnosis of DSM-IV psychiatric disorders and between different diagnoses were performed using either parametric or non-parametric tests, depending on variable distribution. Results: Three hundred and two (10.5%) of 2,870 consecutive CAs made in Turin during a lag time of 8 years were due to unknown psychiatric diagnoses (113; 3.9%) or to psychomotor agitation (189; 6.6%). The most prevalent psychiatric disorders leading to CA were schizophrenia (729; 25.4%), brief psychotic disorder (627; 21.8%), bipolar disorder episode (396; 13.8%), delusional disorder (292; 10.2%), and personality disorder (237; 8.3%). The CAs due to psychiatric disorder were longer (U = 328,875.0; p < 0.001) and involved patients who were more likely to be compulsorily admitted during the study period (U = 357,012.5; p = 0.003), to have had prior contact with a psychiatrist [ χ ( 2 ) 2 = 28.34; p < 0.001], to have had previous admissions to a psychiatric ward [ χ ( 2 ) 2 = 33.06; p < 0.001], to be under the care of psychiatric services [ χ ( 3 ) 2 = 87.01; p < 0.001], and not to have concurrent alcohol [ χ ( 1 ) 2 = 23.06; p < 0.001] and/or drug use [ χ ( 1 ) 2 = 12.97; p < 0.001] than those due to psychomotor agitation/unspecified diagnoses. Conclusion: Despite a history of 35 years of CA made according to a strict need for treatment criteria, the evaluation of CA records shows that a certain proportion of CAs appears to have been due to brief, not psychiatric, alcohol/drug related behavioral conditions. Further studies should confirm the need for law reform leading to the integration between the need for treatment and the danger criteria for CAs.

Involuntary admissions in Italy: the impact of seasonality

OBJECTIVE

The aim of this study is to assess the prevalence of involuntary admissions with regard to seasonality and clinical associated features, in a sample of patients admitted to a psychiatric unit in a period of 24 months.

METHODS

All subjects consecutively admitted to the Psychiatric Inpatient Unit of the San Luigi Gonzaga Hospital, Orbassano (University of Turin, Italy) from September 2013 to August 2015 were recruited. Socio-demographic and clinical characteristics were collected.

RESULTS

Seven hundred and thirty admissions in psychiatric ward were recognized. The prevalence of involuntary admission was 15.4%. Patients with involuntary hospitalizations showed a higher education level, a higher prevalence of admission in spring/summer with a significant peak in June, a longer duration of hospitalization and a lower suicide ideation. Among involuntary admissions, physical restraint and suicide attempts were more prevalent during spring compared to the other seasons.

CONCLUSIONS

Seasonality has an important role in the psychopathology of psychiatric disorders, particularly in bipolar and related disorder, and may represent an influencing factor in hospital admissions and hospitalizations. Seasonal pattern must be considered while managing diagnosis and treatment of mental disorders, with regard to prevention and psychoeducation of patients.

Differences in the use of involuntary admission across the Veneto Region: which role for individual and contextual variables?

AIMS

The first aim of this study is to compare involuntary admissions across the Veneto Region in Italy. The second aim is to explore the relation between mental health services provision, characteristics of population, individual factors and involuntary admissions.

METHODS

For 21 Mental Health Departments (MHDs) in the Veneto Region (Italy), the average population prevalence rate of involuntary admissions between 2000 and 2007 and the percentage of involuntary admissions were calculated. Chi-square tests for equality of proportions were used to test hypotheses. Variables at the individual, contextual and organisational levels were used in multiple regressions, with the involuntary admission data as dependent variables.

RESULTS

The average prevalence rate of involuntary commitment was 12.75 ranging from 1.96 to 27.59 across MHDs . About 75% of the involuntary admissions referred to psychotic patients, and almost half of patients were aged 25-44. Significant differences among MHDs emerged; higher percentages of involuntary admissions were generally found in densely populated areas. Higher ageing indices and rates of social workers were found as predictors of the prevalence rate. In the multilevel regression, being males and psychotic significantly increased involuntary admissions, while the percentage of singles in population decreased it.

CONCLUSIONS

This study contributes to define the specific contribution of each factor predicting the use of involuntary admission, even within areas under the same legislation. It shows how the inclusion of both individual and contextual factors may lead to better predictions and provides precious data for the services improvement.

State of psychiatry in Italy 35 years after psychiatric reform. A critical appraisal of national and local data

Thirty-four years have elapsed since the passing of the Italian Law 180, the reform law that marked the transition from a hospital-based system of care to a model of community psychiatry that was designed to be an alternative to, rather than to complement, the old hospital-centred services. The main principle of Law 180 is that psychiatric patients have the right to be treated the same way as patients with other diseases and only voluntary treatments are allowed, with a few exceptions that are strictly regulated. The main features and consequences of the Italian reform are initially reviewed; national and local level experiences and epidemiological data are then analysed in order to highlight and disentangle the 'active ingredients' of the Italian experience. A public health attitude with the capacity to network good practice in service organization by giving voice to successful experiences and promoting health service research, apart from some local services, is still generally lacking. Furthermore, it is still difficult to provide an evidence-based reply to the question: can à l'Italienne community-care be exported elsewhere?

Factors of importance to involuntary admission

BACKGROUND

Most countries allow for the use of involuntary admission of patients. While some countries have stable or declining rates of involuntary admission, this type of coercion is now on the increase in several European countries.

AIMS

To increase understanding of the antecedents of involuntary admission.

METHODS

The importance of various predictors of involuntary admission were analysed in univariate analyses and in a logistic regression model, involving approximately 2000 admissions to a Norwegian hospital.

RESULTS

Involuntary admission was positively associated with the diagnostic category of psychosis and negatively associated with the category of anxiety. Emergency referrals were also more likely to be coerced.

CONCLUSIONS

Diagnostic category seems to be a central factor with respect to involuntary admission. Patients that were admitted in an emergency were also more likely to be coerced.

CLINICAL IMPLICATIONS

Certain groups of patients are more likely to be admitted involuntarily. Increasing attention to these groups could possibly also contribute to the reduction of coercion.

Does mental health service integration affect compulsory admissions?

BACKGROUND

Over recent years, the number of compulsory admissions in many countries has increased, probably as a result of the shift from inpatient to outpatient mental health care. This might be mitigated by formal or collaborative relationships between services.

METHODS

In a retrospective record linkage study, we compared two neighboring districts, varying in level of service integration. Two periods were combined: 1991-1993 and 2001-2003. We included patients aged 18-60, who had a first emergency compulsory admission (n=830). Their psychiatric history was assessed, and service-use after admission was monitored over a 12-month follow-up.

RESULTS

Over a 10-year period, compulsory admission rates increased by 47%. Difference in relative increase between the integrated and non-integrated services was 14%. Patient characteristics showed different profiles in the two districts. Length of stay was >10 days shorter in the integrated district, where the proportion of involuntary readmissions decreased more, and where aftercare was swift and provided to about 10% more patients than in the non-integrated district.

CONCLUSIONS

Services outcomes showed better results where mental healthcare was more integrated. However, limited effects were found and other factors than integration of services may be more important in preventing compulsory admissions.

Characteristics and activities of acute psychiatric in-patient facilities: national survey in Italy

BACKGROUND

Legislation in 1978 led to the gradual replacement of mental hospitals in Italy with a full range of community-based services, including facilities for acute in-patient care.

AIMS

To survey the main characteristics of Italian public and private in-patient facilities for acute psychiatric disorders.

METHOD

Structured interviews were conducted with each facility's head psychiatrist in all Italian regions, with the exception of Sicily.

RESULTS

Overall, Italy (except Sicily) has a total of 4108 public in-patient beds in 319 facilities, with 0.78 beds for every 10,000 inhabitants, and 4862 beds in 54 private in-patient facilities, with 0.94 beds per 10,000 inhabitants. In 2001 the rates of psychiatric admissions and admitted patients per 10,000 inhabitants were 26.7 and 17.8 respectively. In the same year the percentage of involuntary admissions was 12.9%, for a total of 114,570 hospital days. Many in-patient facilities showed significant limitations in terms of architectural and logistic characteristics. Staffing showed a great variability among facilities.

CONCLUSIONS

The overall number of acute beds per 10,000 inhabitants is one of the lowest in Europe. The survey has provided evidence of two parallel systems of in-patient care, a public one and a private one, which are not fully interchangeable.

Admissions for personality disorders in Italy from 1988 to 1998

BACKGROUND

Personality disorders affect a substantial proportion of the population. It is unclear, however, whether the burden of personality disorders on modern mental health services has been increasing. To fill this gap, we analyzed trends in admissions for personality disorders in Italy from 1988 to 1998.

METHODS

We used the yearly data from the Italian Central Institute of Statistics to analyse trends in the total number of admissions for personality disorders and in the total number of first admissions for personality disorders.

RESULTS

The absolute number of admissions for personality disorders almost trebled from 1988 to 1998, as well as the proportion of all psychiatric admissions that were for personality disorders. Whilst there has been a marked increase in the absolute number of first admissions, the proportion of all first psychiatric admissions that were for personality disorders showed a steady but modest increase, from 5.7% to 7.6%.

CONCLUSION

In Italy, the burden of personality disorders on modern mental health services has been increasing. In terms of public health, these findings highlight the urgent need of developing policies to tackle the increasing demand of care of this difficult-to-treat patient population.